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Dr Kellam New Client Forms Couples SEADOCS:144226.2 TEXAS NOTICE FORM Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I. Uses and Disclosures for Treatment, Payment, and Health Care Operations I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions: • “PHI” refers to information in your health record that could identify you. • “Treatment, Payment and Health Care Operations” – Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist. - Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. - Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. • “Use” applies only to activities within my [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. • “Disclosure” applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties. II. Uses and Disclosures Requiring Authorization I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy. III. Uses and Disclosures with Neither Consent nor Authorization I may use or disclose PHI without your consent or authorization in the following circumstances: Child Abuse: If I have cause to believe that a child has been, or may be, abused, neglected, or sexually abused, I must make a report of such within 48 hours to the Texas Department of Protective and Regulatory Services, the Texas Youth Commission, or to any local or state law enforcement agency. Adult and Domestic Abuse: If I have cause to believe that an elderly or disabled person is in a state of abuse, neglect, or exploitation, I must immediately report such to the Department of SEADOCS:144226.2 Protective and Regulatory Services. Health Oversight: If a complaint is filed against me with the State Board of Examiners of Psychologists, they have the authority to subpoena confidential mental health information from me relevant to that complaint. • Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information, without written authorization from you or your personal or legally appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case. Serious Threat to Health or Safety: If I determine that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, I may disclose relevant confidential mental health information to medical or law enforcement personnel. Worker’s Compensation: If you file a worker's compensation claim, I may disclose records relating to your diagnosis and treatment to your employer’s insurance carrier. IV. Patient's Rights and Psychologist's Duties Patient’s Rights: • Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request. • Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.) • Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process. • Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process. • Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process. • Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically. Psychologist’s Duties: • I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. • I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. • If I revise my policies and procedures, I will notify you in person or by mail and post changes on the web site www.dgapractice.com. SEADOCS:144226.2 V. Complaints If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me at the above phone or address. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request. VI. Effective Date, Restrictions and Changes to Privacy Policy I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by in person or by mail and posting on the web site. SEADOCS:144226.2 Theresa K e l l a m, P h.D., H. S. P. LICENSED PSYCHOLOGIST 2201 Dottie Lynn Parkway, Suite 127, Fort Worth, Texas 76120 817-313-7899 Client Information Questionnaire Today's date: ____________________________ Note: If you have been a patient here before, please fill in only the information that has changed. A. Identification Your name: ______________________________Date of birth: _________________________ Age: ________ Your nicknames or aliases: ______________________________ Social Security #: _____________________ Cell _______________________________________Email ____________________________________ Spouses name: ______________________________Date of birth: _________________________ Age: ________ Spouses nicknames or aliases: ______________________________ Social Security #: _____________________ Cell _______________________________________Email ____________________________________ Home street address: ___________________________________________________ Apt.:_______________ City: _________________________________________ State: ______________Zip: ____________________ Home/evening phone: _______________ Calls will be discreet, but please indicate any restrictions:_________ Cell _______________________________________Email ____________________________________ B. Referral: Who gave you my name to call? Name: ___________________________________________ Phone: ________________________________ Address: ________________________________________________________________________________ ________________________________________________________________________________________ May I have your permission to thank this person for the referral? Yes No How did this person explain how I might be of help to you? _________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ C. Your health care From whom or where do you get your medical care? Clinic/doctor's name: __________________________________________ Phone: ______________________ Address: ________________________________________________________________________________ If you enter treatment with me for psychological problems, may I tell your medical doctor so that he or she can be fully informed and we can coordinate your treatment? Yes No Have you ever been or are you currently in therapy? long? If so, why did you seek treatment, with whom and for how Have you ever taken or are you currently taking any psychotropic medications? If so, what medications did you take, for what symptoms and for how long? Please list all current medications: Name: _______________________ _______________________ _______________________ _______________________ Dose: _______ _______ _______ _______ SEADOCS:144226.2 D. Your current employer Employer: ________________________________ Address: _______________________________________ ________________________________________________________________________________________ Work phone: ________________Calls will be discreet, but please indicate any restrictions: _______________ Spouses Employer: ____________________________ Address: _______________________________________ ________________________________________________________________________________________ Work phone: ________________Calls will be discreet, but please indicate any restrictions: _______________ ________________________________________________________________________________________ E. Your education and training Dates From To Schools ______ _______ ________________ ______ _______ ________________ ______ _______ ________________ ______ _______ ________________ ______ _______ ________________ Spouses education and training Dates From To ______ _______ ______ _______ ______ _______ ______ _______ ______ _______ Schools ________________ ________________ ________________ ________________ ________________ Special Classes? __________________ __________________ __________________ __________________ __________________ Adjustment to school _____________________ _____________________ _____________________ _____________________ _____________________ Did you graduate? ___________ ___________ ___________ ___________ ___________ Special Classes? __________________ __________________ __________________ __________________ __________________ Adjustment to school _____________________ _____________________ _____________________ _____________________ _____________________ Did you graduate? ___________ ___________ ___________ ___________ ___________ F. Employment and military experiences Dates From To Name of military or employers ______ _______ _____________________________ ______ _______ _____________________________ ______ _______ _____________________________ ______ _______ _____________________________ ______ _______ _____________________________ Spouses Employment and military experiences Dates From To ______ _______ ______ _______ ______ _______ ______ _______ ______ _______ Name of military or employers _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ Job title or duties Reason for leaving _________________________ _______________ _________________________ _______________ _________________________ _______________ _________________________ _______________ _________________________ _______________ Job title or duties Reason for leaving _________________________ _______________ _________________________ _______________ _________________________ _______________ _________________________ _______________ _________________________ _______________ G. Family-of-origin history Current age Illness (or cause of Relative Name (or age at death) death, if deceased) Education Occupation Father ___________________ _____________ _____________ ________________ __________ Mother ___________________ _____________ _____________ ________________ __________ Stepparents ___________________ _____________ _____________ ________________ __________ SEADOCS:144226.2 Grandparents __________________ Uncles/aunts __________________ Brothers ____________________ Sisters _____________________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ _____________ ________________ ________________ ________________ ________________ _________ __________ __________ __________ (cont.) Spouses Family-of-origin history Current age Illness (or cause of Relative Name (or age at death) death, if deceased) Education Occupation Father ___________________ _____________ _____________ ________________ __________ Mother ___________________ _____________ _____________ ________________ __________ Stepparents ___________________ _____________ _____________ ________________ __________ Grandparents __________________ _____________ _____________ ________________ _________ Uncles/aunts __________________ _____________ _____________ ________________ __________ Brothers ____________________ _____________ _____________ ________________ __________ Sisters _____________________ _____________ _____________ ________________ __________ H. Marital/relationship history Spouse’s name Spouse’s age at marriage Your age at marriage Your age when divorced/widowed First ____________________ ________ _________ Second____________________ ________ _________ Third____________________ ________ _________ Spouses Marital/relationship history Spouse’s name Spouse’s age at marriage Your age at marriage Second____________________ ________ _________ Third____________________ ________ _________ ______________________ _____________ ____________________ _____________ ______________________ _____________ Your age when divorced/widowed First ____________________ ________ _________ Is spouse remarried? Is spouse remarried? ______________________ _____________ ____________________ _____________ ______________________ _____________ I. Significant nonmarital relationships Name of person Person’s age when started Your age when started First ______________________________ _______ ____________ Second _____________________________ _______ ____________ Third ______________________________ _______ ____________ Your age when ended Reasons for ending ___________ ________________ ___________ ________________ ___________ ________________ Spouses Significant nonmarital relationships Name of person Person’s age when started Your age when started First ______________________________ _______ ____________ Second _____________________________ _______ ____________ Your age when ended Reasons for ending ___________ ________________ ___________ ________________ SEADOCS:144226.2 Third ______________________________ _______ ____________ ___________ ________________ J. Children (Indicate which are from a previous marriage or relationship with the letter P in the last column) Name Current age _________________________ ______ _________________________ ______ _________________________ ______ _________________________ ______ _________________________ ______ _________________________ ______ Sex ______ ______ ______ ______ ______ ______ School Grade _________________ ____ _________________ ____ _________________ ____ _________________ ____ _________________ ____ _________________ ____ Adjustment problems? ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ __ __ __ __ __ __ SEADOCS:144226.2 Theresa LICENSED K e l l a m, P h.D. PSYCHOLOGIST 817-313-7899 [email protected] Adult Checklist of Concerns Name:________________________________________________________ Date: _____________________ Please mark all of the items below that apply, and feel free to add any others at the bottom under "Any other concerns or issues." You may add a note or details in the space next to the concerns checked. (For a child, mark any of these and then complete the "Child Checklist of Characteristics.") I have no problem or concern bringing me here Abuse—physical, sexual, emotional, neglect (of children or elderly), cruelty to animals Aggression, violence Alcohol use Anger, hostility, arguing, irritability Anxiety, nervousness Attention, concentration, distractibility Career concerns, goals, and choices Childhood issues (your own childhood) Children, child management, child care, parenting Codependence Confusion Compulsions Custody of children Decision making, indecision, mixed feelings, putting off decisions Delusions (false ideas) Dependence Depression, low mood, sadness, crying Divorce, separation Drug use—prescription medications, over-the-counter medications, street drugs Eating problems—overeating, undereating, appetite, vomiting (see also "Weight and diet issues") Emptiness Failure Fatigue, tiredness, low energy Fears, phobias Financial or money troubles, debt, impulsive spending, low income Friendships Gambling Grieving, mourning, deaths, losses, divorce Guilt Headaches, other kinds of pains (cont.) FORM 28. Adult checklist of concerns (p. 1 of 2). From The Paper Office, pp. 224– 225. Copyright 1997 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of The Paper Office for personal use only (see copyright page for details) SEADOCS:144226.2 Adult Checklist of Concerns (p. 2 of 2) Health, illness, medical concerns, physical problems Inferiority feelings Interpersonal conflicts Impulsiveness, loss of control, outbursts Irresponsibility Judgment problems, risk taking Legal matters, charges, suits Loneliness Marital conflict, distance/coldness, infidelity/affairs, remarriage Memory problems Menstrual problems, PMS, menopause Mood swings Motivation, laziness Nervousness, tension Obsessions, compulsions (thoughts or actions that repeat themselves) Oversensitivity to rejection Panic or anxiety attacks Perfectionism Pessimism Procrastination, work inhibitions, laziness Relationship problems School problems (see also "Career concerns . . .") Self-centeredness Self-esteem Self-neglect, poor self-care Sexual issues, dysfunctions, conflicts, desire differences, other (see also "Abuse") Shyness, oversensitivity to criticism Sleep problems—too much, too little, insomnia, nightmares Smoking and tobacco use Stress, relaxation, stress management, stress disorders, tension Suspiciousness Suicidal thoughts Temper problems, self-control, low frustration tolerance Thought disorganization and confusion Threats, violence Weight and diet issues Withdrawal, isolating Work problems, employment, workaholism/overworking, can't keep a job Any other concerns or issues: ___________________________________________________________________________________ ___________________________________________________________________________________ Please look back over the concerns you have checked off and choose the one that you most want help with. It is: _____________________________________________________________________________________ This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. SEADOCS:144226.2 Theresa LICENSED K e l l a m, P h.D. PSYCHOLOGIST 817-313-7899 [email protected] Adult Checklist of Concerns Name:________________________________________________________ Date: _____________________ Please mark all of the items below that apply, and feel free to add any others at the bottom under "Any other concerns or issues." You may add a note or details in the space next to the concerns checked. (For a child, mark any of these and then complete the "Child Checklist of Characteristics.") I have no problem or concern bringing me here Abuse—physical, sexual, emotional, neglect (of children or elderly), cruelty to animals Aggression, violence Alcohol use Anger, hostility, arguing, irritability Anxiety, nervousness Attention, concentration, distractibility Career concerns, goals, and choices Childhood issues (your own childhood) Children, child management, child care, parenting Codependence Confusion Compulsions Custody of children Decision making, indecision, mixed feelings, putting off decisions Delusions (false ideas) Dependence Depression, low mood, sadness, crying Divorce, separation Drug use—prescription medications, over-the-counter medications, street drugs Eating problems—overeating, undereating, appetite, vomiting (see also "Weight and diet issues") Emptiness Failure Fatigue, tiredness, low energy Fears, phobias Financial or money troubles, debt, impulsive spending, low income Friendships Gambling Grieving, mourning, deaths, losses, divorce Guilt Headaches, other kinds of pains (cont.) FORM 28. Adult checklist of concerns (p. 1 of 2). From The Paper Office, pp. 224– 225. Copyright 1997 by Edward L. Zuckerman. Permission to photocopy this form is granted to purchasers of The Paper Office for personal use only (see copyright page for details) SEADOCS:144226.2 Adult Checklist of Concerns (p. 2 of 2) Health, illness, medical concerns, physical problems Inferiority feelings Interpersonal conflicts Impulsiveness, loss of control, outbursts Irresponsibility Judgment problems, risk taking Legal matters, charges, suits Loneliness Marital conflict, distance/coldness, infidelity/affairs, remarriage Memory problems Menstrual problems, PMS, menopause Mood swings Motivation, laziness Nervousness, tension Obsessions, compulsions (thoughts or actions that repeat themselves) Oversensitivity to rejection Panic or anxiety attacks Perfectionism Pessimism Procrastination, work inhibitions, laziness Relationship problems School problems (see also "Career concerns . . .") Self-centeredness Self-esteem Self-neglect, poor self-care Sexual issues, dysfunctions, conflicts, desire differences, other (see also "Abuse") Shyness, oversensitivity to criticism Sleep problems—too much, too little, insomnia, nightmares Smoking and tobacco use Stress, relaxation, stress management, stress disorders, tension Suspiciousness Suicidal thoughts Temper problems, self-control, low frustration tolerance Thought disorganization and confusion Threats, violence Weight and diet issues Withdrawal, isolating Work problems, employment, workaholism/overworking, can't keep a job Any other concerns or issues: ___________________________________________________________________________________ ___________________________________________________________________________________ Please look back over the concerns you have checked off and choose the one that you most want help with. It is: _____________________________________________________________________________________ This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. SEADOCS:144226.2 Theresa LICENSED K e l l a m, P h.D. PSYCHOLOGIST 817-313-7899 [email protected] Consent to Treatment I acknowledge that I have received, have read (or have had read to me), and understand the "Information for Clients" brochure and/or other information about the therapy I am considering. I have had all my questions answered fully. I do hereby seek and consent to take part in the treatment by the licensed psychologist named below. I understand that developing a treatment plan with this licensed psychologist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this licensed psychologist. I am aware that I may stop my treatment with this licensed psychologist at any time. The only thing I will still be responsible for is paying for the services I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the court.) I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do not cancel or do not show up, I will be charged for that appointment. I am aware that this licensed psychologist accepts third-party payments. I understand that if payment for the services I receive here is not made, the licensed psychologist may stop my treatment. My signature below shows that I understand and agree with all of these statements. ______________________________________________________ Signature of client __________________ Date ______________________________________________________ Printed name __________________________________________________ Signature of client __________________ Date ______________________________________________________ Printed name ( I, Theresa Kellam, have discussed the issues above with the client (and/or his or her parent, guardian, or other representative). My observations of this person's behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. ______________________________________________________ Theresa Kellam, Ph.D. Licensed Psychologist ____________________________ Date SEADOCS:144226.2 SEADOCS:144226.2